SBAR: Emergency Department 1A S: Charlette LaCour 68-year-old female admitted with pain in left hip and bruising on left arm sustained during a fall at home. Client is accompanied by son Mark who cares for her at home. B: Diagnosed with rheumatoid arthritis and has a history of falls and bruising A: Client is alert and oriented x 4 vital signs are stable, pain and swelling of left hip, left leg is shorter and externally rotated with weak peripheral pulses and coolness to touch indicative of hip fracture. Client expresses fear and anxiety relating to scheduled surgery. R: ED Doctor on call assessed client determining hip fracture and preparation for surgery. Plan to complete pre op check list. 1B S: 12-year-old male brought in by his mother for trouble breathing B: He has a history of asthma. He states he administered Ventolin 2 hours prior to admission A: He has moderate asthma with inspiratory wheezes in all lobes. Peak flow is 190 with his baseline 360. During administration of Ventolin with a spacer, education on slower administration was given. Improper administration at home may have caused the exacerbation of symptoms and admission. His vitals are respirations 26, pulse 90/min, O2 94-95 on room air, temperature is 37.5. R: Monitor respiratory effort and O2 saturation and continue education points related to Ventolin administration as well as refer mother to resources for accessing a current refill for expired medication. 1C S: 30-year-old male admitted with abdominal pain and distention brought who reported vomiting for the last few days B: Past diagnosis of Crohn’s disease A: During initial assessment the client is alert to person with no bowel sounds present with distention, tenderness, and pain 5/10. Physician present reviewed CT scan and identified bowel obstruction and client is scheduled to be seen in the OR. R: Monitor after surgery for post-surgical complications SBAR: Pediatrics S: Post op 10-year-old male Alexander Kovalik, appendectomy Room 110 B: Client name is Alexander but prefers to be called Sasha. Client admitted with appendicitis. Otherwise healthy and no home meds, no allergies. Single mom. A: Alert oriented x 3. Decreased air entry in both lower lobes with pulse ox at 94 resp 26, deep breathing and coughing while splinting incision improved vitals to O2 97% and resp 24. Dressing intact 2cm blood stain, hypoactive bowel sounds in all quadrants, no tenderness on light palpation. Sharp pain at 5/10 pain morphine with dimenhydrinate PO alleviated pain. Relaxation techniques implemented. R: Monitor pain, educate on splinting incision and deep breathing and coughing. Assess anxiety and fears related to surgical incision. Anticipate discharge. SBAR: Maternal S: 21-year-old G1P0 female attending prenatal visit B: Father is unaware of child and not involved at the moment. Client states several supportive family and friends and established support network. Expresses anxiety and feelings related to pregnancy. A: Expected date of birth is November 9. Blood pressure is 98/63, Heart rate is 98 and fetal heart rate is 160. Client educated on orthostatic hypotension and techniques to consider. Fundal height measured at 18cm. Client weight 65.8kg. Client instructed to take prenatal vitamin at bedtime and with orange juice to avoid nausea/vomiting. Client reports frequent voiding. No protein in urine specimen. R: Continue to monitor weight, blood pressure and fetal heart rate/tone, and protein in urine. Educate client on future changes relating to pregnancy. Assess anxiety and fears relating to pregnancy. Refer client to resources that may assist in pregnancy. SBAR: Mental Health S: 38-year-old female single mother Irina Kovalik. Referred for anxious manner related to financial concerns. B: No home meds or current care under physician. Isolated from community. Lives with brother in law Joseph. A: Cluttered living space with used dishes on table and countertops. Bruising on arm from Joseph who is living in apartment. Client states joseph pays rent and groceries on occasion. Joseph may be the brother of Irian’s husband who has not been present for over a year. Potential abuse and violent temper observed during brief presence of Joseph. Irina expresses thought of harming herself at times but does not have a plan. R: Follow up appointment to discuss resources and further understand the situation.
